by Liz Highleyman

A Republican proposal to repeal and replace the Affordable
Care Act will lead to millions of people losing their health insurance and
raise costs for low-income and older individuals, according to opponents of the
plan. People living with HIV or other chronic conditions likely will be heavily
affected.

The proposal aims to revoke the ACA's Medicaid provisions,
which would have a big impact in states that opted to receive federal funds to
expand their programs. But some cities and states are making contingency plans
to continue coverage for vulnerable residents.

"In San Francisco, the Affordable Care Act has worked.
It has provided stability for many people, cut our uninsured population by half,
and strengthened the health care system, making us a healthier city overall,"
lesbian Health Director Barbara Garcia told the Bay Area Reporter. "While
there are significant threats to the health care system being discussed at the
federal level, here in San Francisco we are committed to providing access to
high quality health care for everyone, and that has not changed."

The ACA has extended health coverage to 133,000 San
Franciscans, including 93,000 covered under expanded Medi-Cal (California's
Medicaid program) and 40,000 who purchase coverage through Covered California,
mostly using federal subsidies, according to Garcia. She estimated that the
Republican plan could lead to a loss of $125 million for local health care
providers, hospitals, and clinics.

Proposed changes

House Speaker Paul Ryan (R-Wisconsin) unveiled the American
Health Care Act March 6. The Republican plan would roll back Medicaid expansion
by the year 2020, revoke the requirement that individuals must carry health
insurance and most employers must provide it, cut taxes that bankroll the ACA,
and stop federal funds going to Planned Parenthood.

The AHCA keeps the ACA's prohibitions on lifetime spending
caps and refusal to cover people with pre-existing conditions, and allows young
people to stay on their parents' policies until age 26. It removes the ACA's
tax penalty on people who do not carry insurance, but those who do not maintain
continuous coverage would face increased costs. The proposal expands health
savings accounts, adds some funding for community health centers, and gives
states more support to assist "high-risk" individuals.

According to a Congressional Budget Office report released
this week, the AHCA would slash federal spending on Medicaid by 18 percent, or
about $880 billion. Over time the changes would lower the federal deficit by
$337 billion. An estimated 14 million Americans could lose their health
coverage next year, rising to 24 million being uninsured by 2026.

Health and Human Services Secretary Tom Price told reporters
that the CBO's figures "defy logic," but an internal White House
analysis reportedly put the number of people who would lose insurance even
higher, at 26 million.

Instead of federal subsidies based on income, under the
Republican plan people would receive tax credits based on age. While some young
and healthy individuals could see lower monthly premiums, costs are expected to
skyrocket for older individuals. Subsidy reductions would be largest in
high-cost states.

As an example, the CBO calculated that under the ACA, people
of any age earning $26,500 a year would pay $1,700 annually in subsidized
insurance premiums. Under the AHCA, premiums for a 21-year-old would fall a
bit, to $1,450, while premiums for a 64-year-old would rise to $14,600 –
more than half their income.

Negative reaction

So far response to the AHCA has been largely negative.

"As drafted, the AHCA would result in millions of
Americans losing coverage and benefits," American Medical Association
president Dr. Andrew Gurman said in a statement. "By replacing
income-based premium subsidies with age-based tax credits, the AHCA will also
make coverage more expensive – if not out of reach – for poor and
sick Americans."

The American Nurses Association, American Public Health
Association, American Hospital Association, and AARP have also opposed the
plan, while America's Health Insurance Plans – the insurance industry's
largest trade association – expressed reservations about parts of it.

Some Republican legislators – especially from states
that have expanded Medicaid – fear the plan could hurt them politically.
And some Donald Trump supporters have criticized the plan, citing the
president's promise that people would not lose their coverage or be worse off.
At the same time, some conservatives and libertarians complain that the plan
does not go far enough in dismantling the ACA, also known as Obamacare.

LGBT and people with HIV hard hit

LGBT people and people living with HIV or other chronic
conditions will be particularly hard hit by replacing the ACA with the
Republican plan, according to several officials.

"The LGBT community traditionally, and for many, many
years, has lacked the same access to health care as the community at-large. For
that reason, the Affordable Care Act was an absolute godsend for many LGBT
people," said gay state Senator Scott Wiener (D-San Francisco), speaking
in favor of a Senate resolution opposing the AHCA. "The repeal, or
demolition, or whatever you want to call Trump and Congress' gutting of the ACA
will have profoundly negative consequences for LGBT people around this country,
ranging from increased HIV infection rates to more people dying from HIV to
more transgender people experiencing severe health problems."

Rolling back Medicaid expansion would have a disproportionate
impact on HIV-positive people. Medicaid is the largest source of insurance
coverage for people with HIV, covering more than 40 percent, according to the
Kaiser Family Foundation.

"People with HIV, hepatitis C, and other chronic
conditions will be devastated by proposed cuts to the Medicaid expansion and
proposals to make health coverage more expensive for older Americans,"
Emalie Huriaux, Project Inform's director of federal and state affairs, told
the B.A.R. "If the Medicaid expansion is eliminated, many of these
individuals will have nowhere else to go for affordable coverage. If health
coverage is unavailable or unaffordable, many individuals with HIV and
hepatitis C will go without the care and treatment they need."

The HIV Medicine Association, which represents nearly 5,000
physicians, scientists, and other health care professionals working in the
HIV/AIDS field, expressed concerns about the Republican proposal.

"If advanced, the ACA replacement bill stands to
threaten our progress in diagnosing and treating patients with HIV and increase
healthcare disparities both between states and based on socioeconomic status,"
said HIVMA Chair Dr. Wendy Armstrong. "These proposals will not only harm
individuals with HIV, but will compromise our nation's public health by leaving
fewer with access to the antiretroviral treatment that keeps patients healthy
and reduces their risk of transmitting HIV to near zero."

The National Alliance of State and Territorial AIDS
Directors, National Coalition of STD Directors, National Minority AIDS Council,
AIDS United, and the AIDS Institute also issued a joint statement opposing the
Republican plan.

"We believe that the proposed legislation would make it
much harder, if not impossible, for people living with HIV and other chronic
conditions to get the coverage needed to meet their care and treatment needs,"
said NASTAD executive director Murray Penner. "We need a system of health
coverage that works for everyone, including people with chronic conditions and
disabilities and the proposed legislation achieves the exact opposite."